Halloween Haunted House
Want to know what toxin you can find at a haunted house? How it’s responsible for world-wide outbreaks, poisoning thousands, many of the victims children? How too much exercise can cause kidney failure?
This is the Pick Your Poison podcast. I’m your host Dr. JP and I’m here to share my passion for poisons in this interactive show. Will our patient survive this podcast? It’s up to you and the choices you make. Our episode today is called Halloween Haunted House. Want to know what toxin you can find at a haunted house? How it’s responsible for world-wide outbreaks, poisoning thousands, many of the victims children? How too much exercise can cause kidney failure? Listen to find out!
I’m excited to share the first podcast’s Halloween episode. It starts at a Halloween Haunted House. You’re in line with your friends, listening to the screaming from inside thinking there’s still time to escape to the corn maze when you reach the ticket booth. As the cashier passes back your credit card, she turns to a man behind her and tells him to go home if he doesn’t feel well.
Your friends, I’m using the term loosely, drag you inside the haunted house before you can change your mind. It resembles an abandoned psychiatric hospital complete with ghosts and zombies of former patients. Rationally, you know it’s a plywood set constructed in a field, but lights, fog, mirrors and fake zombies are nevertheless terrifying. You fear a heart attack, but manage to escape unscathed with your cardiovascular system, mostly, intact.
Gasping for breath and laughing at yourselves outside the exit, you see a man stumble past, clutching his abdomen. He stumbles and falls down. You assume he’s drunk or high, like many other participants. He doesn’t get up. You go over to help him. He’s awake and alert, but weak and having difficulty standing on his own. You recognize him as the staffer in the ticket booth feeling unwell.
It’s dark out, but even so you can see he doesn’t look good and you recommend he go to the emergency department. He refuses, saying he’ll go home and rest. Eventually, it’s clear he won’t be able to get to his car much less drive, so he agrees.
Of course, today is probably your day off, but let’s change the scene to the Emergency Department so we can find out what’s happening. The man is 27 years old and says he’s had three days of back pain, abdominal pain, body aches and dark urine. He's been extremely itchy, all over, but doesn't have a rash. He denies everything else including pain with urination or blood, fever or chills, cough and recent upper respiratory infection.
He denies past medical history, doesn’t take any medicines, over-the-counter medicines or supplements. No tobacco, alcohol and illicit drugs. His vital signs are unremarkable. On physical exam, he’s generally weak. He can move all of his extremities, but doesn’t have the strength you’d expect from a healthy 27-year-old. There’s no focal weakness in one leg or arm, this is generalized weakness. Everything else is completely normal.
You order basic lab work and a urinalysis. His labs come back quickly for a change. Hmm. His creatinine is 8mg/dL (or 700 mmol/L). Normal is around 1 mg/dL. His potassium is 7 mEq/L (or mmol/L) also very elevated. This is kidney failure. It explains his symptoms, nonspecific pain, muscle aches and itching. The renal failure causes elevated potassium because it isn’t being eliminated. The kidneys eliminate toxins from the body, including natural byproducts of metabolism, they also regulate many electrolytes including potassium. High potassium, in turn, causes muscle weakness because your muscles can’t function properly.
What now? First, elevated potassium is an emergency. Very high levels, and he’s in this range, can cause cardiac arrest. Remember your heart is a muscle and if it can’t contract, that’s bad news. There are many different medicines to treat the high potassium, including albuterol, a breathing treatment, insulin and bicarbonate, just to name a few. These drive potassium inside cells, temporarily reducing the serum potassium level. Potassium binders, like loKalemia, binds to potassium so it’s excreted in stools. Pooping out the potassium. I’d order all of these, but what he really needs is emergent dialysis to get rid of potassium and the other acids and natural toxins.
You go back in the room to convey the news and get some more information. Renal failure is the cause of his symptoms. But what’s the cause of the renal failure?, he asks. Good question. This is an unusual case, of course anyone can develop kidney failure anytime, but it's not common in an otherwise healthy 20-year-old. You ask why he waited so long to come to the ED. He must’ve been feeling terrible. Had he come earlier, we might’ve caught the kidney failure at an earlier stage, before he needed dialysis. He says he’s uninsured and is afraid of the hospital bills. If you’re not American you might not believe this, but it is sadly, a daily occurrence in the US.
So, causes of renal failure. There are many hereditary causes, he reports no family history of kidney disease. Diabetes and hypertension, of course, but he doesn’t have these. One thing I’d definitely consider is rhabdomyolysis, rhabdo for short. This is muscle breakdown, resulting in kidney failure. Creatinine kinase is the lab test to check for this. Question #1. Which of the following causes rabdo?
A. Cocaine
B. Eating quails
C. Exercise
D. Statins (cholesterol lowering drugs)
E. All of the above
Answer: E all of the above. It does happen in young healthy people, often after extreme exercise, or with drugs like cocaine. For example, 12 lacrosse players at Tuft university recently were hospitalized with this after a workout by a Navy Seal graduate. Statins notoriously cause muscles aches and can lead to rabdo. Ingesting quails has also occasionally caused rabdo and renal failure, though the cause is uncertain.
The creatine kinase comes back normal, excluding rhabdo.
You admit the patient to the hospital. He needs a lot more workup, at this point, it’s for nephrology to solve not emergency medicine. Two days later, you check his chart. He started dialysis with improvement in both his potassium and his symptoms. I’m speeding up the timeline a bit, his renal biopsy shows acute interstitial nephritis.
Interstitial nephritis can be caused by infections or autoimmune disease, like lupus but it’s interesting because it’s often caused by drugs. What drugs? Antibiotics, a lot of them. Antivirals like medicines for HIV or acyclovir, for herpes, shingles and other viral infections. Drugs for GERD and gastritis, like pantoprazole ie Protonix and famotidine ie Pepcid. A huge and very, very common category are anti-inflammatories. When you hear about ibuprofen, brand name Motrin causing renal failure this is what it does. You don’t expect to get a tox consult as nephrology is excellent at managing these cases.
The next day, you do get a call for a toxicology consult. Not from nephrology but from neurology. Neurology? What's happening now? The neurologist says the patient has developed a 7th cranial nerve palsy, a facial droop, like you’d see with a stroke. She’s done an extensive workup including an MRI of his brain. It was negative for stroke, though it showed some very nonspecific abnormalities. Nephrology hasn’t found the cause of the interstitial nephritis either and both have exhausted their list of differential diagnoses for the cause of these problems. As is often the case with toxicology consults, they are calling for help in the hopes that you can find something that they didn't.
At this point, the patient’s been in the hospital for 4 days, about a week since the onset of his symptoms. You go to his room and re-examine him. He’s awake and alert with normal vital signs. The left side of his face is now drooping. You find some weakness in his left arm compared to the right arm. It's subtle, but present. Essentially, we have a patient with renal failure and neurological problems. For certain, this can represent not just a constellation of toxins, but a constellation of diseases. However, the two taken together should be a big, red flag for toxicologists.
You ask the patient about suicidal thoughts, he denies any self-harm attempt and again denies medicines and supplements, etc. Occupational exposures are always a consideration for toxins, you ask him more about his job at the haunted house. He says he’s a special effects artist, the reason he was hired by the haunted house.
You ask about a typical word day, in the hopes something might come to light. He says he sets up and adjusts lighting and projectors. Not many tox problems associated with lights and projectors. He helped decorate with fake spider webs and glow in the dark objects. Could it be the fake cobwebs? No, those are just fabric like cotton or polyester. What about glow in the dark decorations. Question 2.
What is the source of the most common calls to poison centers on Halloween?
A. poisoned candy
B. poison apples
C. glow sticks
D. Face paint
Answer: Glow sticks. They have minimal toxicity, apparently tons of kids eat them, their worried parents call the Poison Center. Ingesting them isn’t an issue, occasionally they cause irritation, like if the liquid gets onto the skin or eyes. The treatment is irrigation, washing it off with water.
So, not the glow-in-the-dark decorations. You think back to your haunted house tour, trying to picture potential toxins. Most of what you can remember is your heart pounding and your own screaming. He says he also used fog machines extensively for ambiance.
Fog machines. Is the smoke toxic? No, so called fog juice is used to make it, but the concentration of the ingredients is very low in the smoke. This haunted house, additionally, was outside, so it’d be impossible for anything in the fog to become concentrated enough to poison anyone. You and your friends are totally fine after exposure to the smoke.
What about the fog juice itself? There is a toxic ingredient in many formulations. Time to pick your poison. Question 3. What is it?
A. Methanol
B. Ethanol ie alcohol
C. Sodium hypochlorite
D. Diethylene glycol
Answer: D. This is diethylene glycol poisoning. It’s not alcohol poisoning, sodium hypochlorite is bleach, caustic, but not a cause of renal failure. Methanol is in moonshine and causes blindness.
Diethylene glycol is a toxic alcohol. We discussed toxic alcohols in the White Lightning Episode, so for more details about toxic alcohols in general I would encourage you to listen, as I don't want to be too repetitive here. I'm going to focus specifically on diethylene glycol today, because it is a really fascinating poison, responsible for worldwide outbreaks, which I’ll get to in a few minutes.
After ingestion of diethylene glycol or DEG, you initially get the classic toxic alcohol findings of elevated anion and osmolar gaps. If you are screening a patient who might’ve ingested some, these labs help you decide if a patient was or wasn’t exposed and can suggest severity of poisoning. In real life however, most cases of diethylene glycol exposure aren’t diagnosed until much later. The lab abnormalities only last a day or so, and as with our patient, won’t be present later.
How does diethylene glycol work and what does it do? Our patient has the classic progression of symptoms starting with renal failure and progressing to neurological findings. As with other alcohols, ingestion of DEG can cause lethargy, confusion and intoxication, like with regular old alcohol. It’s broken down in the body to toxic metabolites, harmful in this case to kidney cells and nerves, causing renal failure and neurological problems.
I want to tell you about an outbreak of DEG poisoning in Panama. It began as a medical mystery and illustrates the symptoms really well. In 2006, a neurologist was consulted on several patients for possible Guillain-Barre syndrome. This is a very rare disease causing progressive muscle paralysis. It’s not the kind of thing you see frequently, and even a neurologist wouldn’t get more than one consult a day about this disease. He also noted the patients were in renal failure, not typically associated with Guillan-Barre or most other neurological diseases for that matter.
He reported the unusual cluster of cases, leading to an investigation. First, the patients developed kidney disease and renal failure, typically within 1-3 days, then 24-48 hours later, neurologic problems, often a facial droop, then extremity weakness and paralysis, it could progress to encephalopathy, meaning altered mental status, seizures, coma and death.
Infectious etiologies like viral encephalitis were excluded. Suspicion next fell on lisinopril which most of the patients were taking. All were getting their medications from the countries public health system pharmacy. Testing of the lisinopril was negative. One of the side effects of lisinopril is a cough and eventually, an association was noted with diabetic cough syrup. DEG in the cough syrup was the culprit. At least 400 people died as a result, though some suggest the numbers are more likely in the thousands.
How did this contamination happen and why? Sadly, the story has occurred over and over agin. Glycerin is a mostly nontoxic ingredient used itself as a medicine for constipation and used in medicines as a diluent. In Panama, as in other places, toxic DEG was substituted for benign glycerin.
Back to our patient. We know what happened, even if we don’t know how or why he was exposed. Can we send a test for DEG? Yes, it will take a long time to result. The clinical picture is proof enough. What’s the treatment? If you remember, we do have an antidote for toxic alcohols, fomepizole. Should we give it?
Question 4.
A. Yes
B. No
Answer: Actually no. It’s too late, the antidote can’t help. Fomepizole works by blocking the conversion of the toxic alcohol to the poisonous metabolites. The conversion happens hours or at most days after exposure. Even if we’d made the diagnosis in the ED, three days after he got sick, fomepizole probably wouldn’t have helped, because he doesn’t still have the original DEG in his body. Dialysis can help with removal of the toxic metabolites, which he’s already getting.
Ok, so we understand how it works and are doing what we can for treatment. Let’s get back to how he was exposed to DEG? After some further questioning, the patient reports, one day at work he drank from a water bottle. After gulping down a few swallows, he realized it tasted funny and spit out the last mouthful. My best guess? Someone put the DEG into a water bottle, without labeling it, for storage and our patient accidently drank it.
Think this is a ridiculous scenario? It isn’t and is in fact, a very common call to poison centers. Someone drinking out of a bottle, unwittingly exposing themselves to a non-beverage liquid. For some reason, it’s often a Snapple bottle. People store cleaning fluids, engine fluid, and all sorts of other toxic stuff in unlabeled bottles. Please don’t do this without at least labelling the bottle. Fog fluid is safe in the fog itself, because the DEG is in a very low concentration. But it’s much more concentrated in the juice. There's an unusual case published by a Dutch Poison Center where a man unwittingly used fog fluid to make coffee, developing significant toxicity. Researching for this episode, I found fog juice for sale advertising nontoxic ingredients, interestingly glycerin instead of DEG.
Is there any hope for recovery for our patient? It’s hard to predict, data’s conflicting. It seems patients can recover renal function, if the kidney injury isn’t severe enough to require dialysis. But once on dialysis, most patients stay on dialysis unfortunately for him. On the other hand, it seems neurological symptoms might improve with time. It’s too early to tell for our patient, we’ll have to wait and see. This is a fictional case, as are all our cases, to protect the innocent. But it is based on real poisonings.
DEG is a toxin with a fascinating history. In the US, it’s responsible for the modern FDA. In 1937, several hundred people died after exposure to elixir of sulfanilamide, an antibiotic that became known as the Elixir of Death. The Massengill pharmaceutical company wanted to make a liquid preparation of the new wonder drug sulfanilamide, especially for children with strep throat. They used DEG as the diluent, poisoning hundreds. Incredibly, at that time, the FDA didn’t have the power to stop the sale of Elixir of Sulfanilamide because it was toxic. The only reason they could intervene at all is because of mislabeling. An elixir is made with alcohol, or ethanol, which elixir of sulfanilamide didn’t contain. Afterward, the FDA was given more power to oversee safety of drugs. If you're interested in the history of DEG and more about the FDA, check out my guest appearance on the Toxic History podcast for more. The podcast is an amazing treasure trove of fascinating poisons and outbreaks.
Despite knowledge of DEG toxicity for almost 100 years, outbreaks happen with disturbing frequency worldwide. It’s been found in toothpaste, cough syrup and liquid acetaminophen, for this reason, children are often the victims. Typically, DEG is substituted for glycerin. In some cases, maliciously, as it’s cheaper than glycerin, and in others mistakenly.
I thought this would be an interesting topic for a Halloween episode, rather than say poisoned candy. Despite what the news, or maybe your mother would have you believe, there has never been a case of a child maliciously poisoned by Halloween candy ever in the US.
A few Halloween tips, marijuana edibles are not good for children or pets. Superglue is not a good way to apply false eyelashes. Chocolate is lethal to dogs and cats.
Last question in todays podcast. In the UK in the town of Bradford, on October 31 in 1858, children became sick and died after eating peppermint candy. What was the candy accidently laced with? (Hint. One of the children was initially diagnosed with cholera.)
A. Arsenic
B. Cyanide
C. DEG
D. Thallium
Follow the Twitter and Instagram feeds both @pickpoison1 and you’ll see the answer when I post it. Remember, never try anything on this podcast at home or anywhere else.
Thanks so much for your attention. It helps if you subscribe, leave reviews and/or tell your friends. Transcripts are available on the website at pickpoison.com.
While I’m a real doctor this podcast is fictional, meant for entertainment and educational purposes, not medical advice. If you have a medical problem, please see your primary care practitioner. Thank you. Until next time, take care and stay safe.